摘要
目的评价慢病管理团队主导的高血压管理对患者血压控制状况、疾病相关花费及生活质量的影响。方法采用随机对照研究,共纳入高血压患者538名。其中由慢病管理团队管理的高血压患者为266例(团管组),平均年龄为62.8岁;常规门诊专科医师管理的患者为272例(常管组),平均年龄为64.5岁。团管组干预内容包括与患者互动式沟通完成治疗及生活方式调整方案的商讨和确立,定期随访血压控制的状况及对依从性障碍问题的解决。常管组干预的内容包括患者治疗方案制定、健康教育及治疗过程中的血压控制水平的计划性随访。结果随访结束时,团管组患者血压控制率达92.9%,而常管组则为75%(P<0.001);团管组收缩压和舒张压的改善程度均大于常管组(分别为P=0.006及0.008)、更少的疾病相关经济花费分别为[(61.4±30.6)元及(75.4±39.1)元,P<0.006]和更好的慢病管理服务体验及更高的生活质量。结论慢病团队主导的慢病管理模式,通过提供更加个体化的治疗方案,可有效地改善高血压患者的血压控制状况、减少疾病相关的经济费用和改善患者的生活质量。
Objective To assess blood pressure（BP）control status,disease-related economic costs as well as quality of life of patients with hypertension managed by Chronic disease management team vs routine clinic Interview.Methods 538 patients were randomly assigned to chronic disease management team-Led group（n=266,mean age 62.8years）or routine clinic Interview group（n=272,mean age 64.5years）.Interventions of the chronic disease management team-led included discussion and development therapeutic and lifestyle modification plan by interaction with patients,regular follow-up for blood pressure control and problem solving to address barriers to adherence.Measures of routine clinic interview group included development of treatment,healthy Education and planned follow-up for blood pressure control status.Results Compared with routine clinic interview group,patients in the Chronic disease management team-led group had more satisfactory blood pressure control rate（92.9%75%,P〈0.001）and blood pressure level and,less disease-related economic costs（RMB$61.4±30.675.4±39.1,P〈0.006）and better delivered chronic disease care services as well as quality of life.Conclusions Interventions delivered by Chronic disease management team using individualized treatment regimens can be an effective approach to improve blood pressure control in hypertensive patients,reduce disease related economic costs and improve the quality of life of patients.
出处
《西部医学》
2015年第10期1522-1525,共4页
Medical Journal of West China
基金
四川省卫生厅科研课题(100335)
四川省南充市科技基金项目(2010SF18)
关键词
慢病管理团队
专科护士
高血压
血压控制率
生活质量
Chronic disease management team
Specialist nurse
hypertension
Blood pressure control rate
Quality of life
